Updates on BLS and ACLS

Updated on December 5, 2012

Source

Whether you have taken CPR courses a thousand times, or are
simply considering taking it because a family member has recently had an
emergency, or you just want to be prepared, the skills learned in the BLS and
ACLS courses are extremely valuable. There are a number of resources online
that give the basics of CPR, but recently the American Heart Association (AHA)
has made a number of important changes in an attempt to improve the quality of
CPR and consequently improve outcomes. Information for this Hub was found using
the Advanced Cardiovascular Life Support Provider Manual: Professional.

Disclaimer: These skills can be life saving and it is very important that they are taught by a professional who is trained in how to properly teach these techniques. This article is not meant to teach anyone the information and techniques needed to perform these skills. It is merely meant to provide an overview of what each protocol is and information regarding updates for those who may be re-certifying or looking into a CPR course.

What are the Difference Between BLS and ACLS?

Basic Life Support (BLS) is intended to teach emergency
responders of all levels the skills needed to recognize life-threatening
situations and respond correctly by performing CPR, using an automated external
defibrillator (AED), or relieving choking using various methods. The basic
steps in the BLS survey include: checking level of responsiveness, activating
the emergency response system, checking for a pulse and providing
defibrillation if appropriate. BLS is typically provided prior to the patient
reaching the hospital, and can be provided by almost anyone, including school
teachers, day care providers, sports coaches, etc. Advanced Cardiac Life
Support (ACLS) provides a more advanced response by further analyzing and properly treating
emergency situations. It also differs from BLS in the range and invasiveness of
resources available for the ACLS certified health professional to use. Healthcare professionals trained in ACLS must
understand the use of assisted breathing devices, have the skill set to gain IV (or IO)
access, and knowledge of appropriate pharmacologic therapies.

The Basics of BLS

BLS in based on a system of 4 steps designated 1-4. These 4
steps are always performed in the same sequence. First the responder checks
responsiveness by loudly asking if the person is alright and scans the chest
for any evidence of breathing by looking for movement. The second step in the
BLS sequence is to make sure that proper help is called and that an AED is
retrieved if available. It is important to be direct in asking bystanders to
perform certain tasks. For example, instead of saying “someone call for help”,
point to a particular person and say “You, go call 911 and you go retrieve an
AED and bring it back”. A carotid pulse is then checked in the 3rd
step and in the absence of a pulse, chest compressions are started immediately. The final step in the BLS
process is the use of an AED to determine heart rhythm to decide is shock is
advisable. Typically, BLS is continued until care can be passed off to
individuals capable of higher, more intensive levels of care.

Recent Updates to the BLS Protocol

The AHA’s new model for successful resuscitation
is represented by links within a chain. This chain, known as the Chain of
Survival includes: recognition of the situation as cardiac arrest and
activation of the emergency response system, early CPR that is high-quality and
focuses on chest compressions, use of an AED rapidly if one is present to
defibrillate shockable rhythms, effective ACLS, and proper care post cardiac
arrest. These steps are those that were previously discussed in the Hub and
were designated 1-4.

Prior to 2010, the AHA’s model for resuscitation
was represented by the pneumonic ABCD, which encompassed airway, breathing,
circulation, and defibrillation. It is now recommended that chest compressions
be started prior to giving any rescue breaths at a rate of at least 100 compressions/min at a depth of 2 inches and allowing the chest to recoil completely between each
compression. This is a change from the prior recommended sequence of airway,
breathing, circulation (ABCs) to circulation, airway, breathing (CAB). The emphasis
is now placed on starting adequate chest compressions (as defined above) in a
pulseless patient as early in the resuscitation process as possible.

Providers no longer look, listen, and feel for
breathing. Instead providers are instructed upon initial approach to the
patient to scan the chest for any evidence of movement. It is important to
remember that agonal gasps are not considered to be an effective breathing
pattern.

The AHA now places the continuous delivery of high quality CPR, with minimal breakage of
compressions, at the forefront of CPR protocol. The new 2010 guidelines state
stat stoppage of chest compressions for any reason (to check a pulse, apply AED
pads, give rescue breaths in single responder CPR, etc.) should not exceed 10 seconds.

Lastly, if more than one responder is present,
responders should swith roles every 2
minutes (or 5 cycles of 30 chest
compressions) to avoid fatigue and keep compression depth adequate at 2 inches.

The Basics of ACLS

ACLS lays out the proper treatment techniques for various
emergency situations using a number of algorithms. Such emergency situations include:
cardiac arrest, stroke, and cardiac rhythm disturbances. Unlike BLS, there
isn’t a defined sequence of events, instead I think of it as one of those story
books where the reader chooses the ending. The algorithms are like recipes, but
the provider has to have enough training to put the right recipe with the
correct patient and tools. If the provider is not properly trained, it would be
like using a pizza recipe and a blender to make a cake! ACLS expands upon the
foundations taught in basic CPR courses. Chest compressions and maintaining
perfusion are the most important things, and without this foundation it doesn’t
matter what drugs get thrown at a patient they are still doing to have a poor
outcome.

ACLS Protocol Updates

Waveform capnography is now used as the most
reliable method of confirming and continuously monitoring placement of an
Endotracheal (ET) tube.

As of 2010, the use of cricoid pressure is not
advised in maintaining a patient’s airway.

Chest compressions should be continued while the
defibrillator or AED is being prepared
or charging, so as not to interrupt chest compressions any longer than
necessary. As stated above, the maximum amount of time there should be a
breakage in the chest compression cycle is 10 seconds.

All advanced interventions, to include: obtaining
IV access, placing an advanced airway, and giving medications should be
performed around the cycle of chest compressions to keep chest compressions as
continuous as possible. The AHA guidelines recommend performing such procedures
during the brief pause in chest compressions that occurs immediately following defibrillation.

Atropine is no longer recommended for use within
the AHA’s PEA/asystole algorithm.

The 2010 guidelines set new electrical parameters
for the cardioversion of unstable patients. See table below.

The AHA has deemed 5 things critical to the post-cardiac
arrest care of the patient that has achieved return of spontaneous circulation
(ROSC). These things include: optimizing the patient’s hemodymanics, getting a
12 lead EKG, induction of hypothermia, the use of waveform capnography to
continually monitor the airway, and optimization of arterial oxygen saturation.

2010 Guidelines for the Initial Biphasic Dose in Cardioversion of Unstable Patients

Rhythm

Initial Biphasic Energy Dose

Unstable Atrial Fibrillation

120-200 J

Unstable SVT or Unstable Atrial Flutter

50-100 J

Unstable Monomorphic VT

100 J

Let's Recap!!!

Look, listen, and feel followed by 2 rescue
breaths has been eliminated from the BLS procedure to facilitate more rapid
initiation of chest compressions. We now start with chest compressions instead
of giving 2 rescue breaths.

The BLS procedure is no longer represented by
the pneumonic A,B,C,D, as this sequence delays starting chest compressions,
instead it is represented within the Chain of Survival by the numbers 1,2,3,4.

High quality CPR is defined as chest
compressions at a rate of at least 100 compressions/min at a depth of 2 inches
allowing for complete recoil between compressions.

Chest compressions should be continued while the
AED or defibrillator is being readied and while it is charging in efforts to
minimize breaks in chest compressions. Stoppage of chest compressions for any
reason should be limited to <10 seconds.

It is important to be properly trained in
BLS or ACLS techniques. It is also important to be re-certified and updated on
changes in procedure, so that those we help can have the best possible outcomes.

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